Ryan D. Lewis MD MHA Capstone Advisor: Ayse Gurses, PhD, Assistant Professor, Department of Anesthesiology and Critical Care Medicine The Johns Hopkins.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Slide 1
Ryan D. Lewis MD MHA Capstone Advisor: Ayse Gurses, PhD,
Assistant Professor, Department of Anesthesiology and Critical Care
Medicine The Johns Hopkins School of Medicine Can a Device-Use
Checklist Reduce Medical Errors in the Operating Room? A Literature
Review
CISDs Image Source: Dr. Grobelney performs endovascular
surgery; chicagovascularsurgery.com; Gore Neuroprotection System;
touchcardiology.com
Slide 8
CISDs 20 potential adverse events listed 60 (approx) procedural
steps Image Source: The Gore Helex Septal Occluder; gore.com; The
Helex Septal Occluder; scielo.br
Slide 9
Checklists in Aviation Image Source: Wright brothers airplane,
xtimeline.com
Slide 10
Checklists in Aviation Image Source:Test flight of B-17; B-17
test flight crash How the pilots checklist came about,
atchistory.org
Slide 11
Image Source: Approved B-17F and G checklist, pilots duties in
red, galbreath.net
Slide 12
Could CISDs Benefit From Checklists? Image Source: Glass
cockpit, amevoice.com; Printable wedding checklist,
portaweddings.com; Robotic surgery, spectrum.ieee.org
Slide 13
Methodology Literature search for articles relating to:
Checklists in medicine, surgery, for surgical devices
Device-related adverse events Distributed cognition theory Adverse
events and memory/distraction Human error theory Instructions for
use Others No articles found describing checklists for CISDs
Slide 14
Results Description of the public health problem Magnitude of
the problem Causes and determinants Prevention and
intervention
Slide 15
Magnitude of the Problem Medical Errors Device-Related Errors
Surgical Device Errors Complex-Invasive Surgical Device
(CISD)Errors 44,000-98,000/year = $24 billion 1 83.7/1000 hospital
visits 2 ??? MAUDE/manufacturers database 1.To err is human:
Building a safer health system - summary [Internet].; 1999.
Available from:
http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf.http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
2.Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and
nature of surgical adverse events in colorado and utah in 1992.
Surgery. 1999 Jul;126(1):66- 75. = 1.5 jetliners crashing every day
1
Slide 16
Causes and Determinants Lack of experience or competence with a
procedure (53%) 1 Breakdown in communication (43%) Fatigue (33%)
Interruptions/distractions during a procedure Inappropriate
protocols 1. Gawande AA, Zinner MJ, Studdert DM, Brennan TA.
Analysis of errors reported by surgeons at three teaching
hospitals. Surgery. 2003 Jun;133(6):614-21.
Slide 17
Human/System Limitations 7 2 Image Source: James Reasons Swiss
cheese model, thereliabilityroadmap.com; Seven chunks plus or minus
two, thelatherapistblogspot.com; Image of a person doing math with
a paper and pencil,tamu-commerce.edu
Slide 18
Prevention Greater than 50% of surgical injuries are
preventable 1 1. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The
incidence and nature of surgical adverse events in colorado and
utah in 1992. Surgery. 1999 Jul;126(1):66-75. Image Source: A
central line placed in a patient, blog.timesunition.com
Discussion Checklists work Devices are becoming more complex
Limitations of the literature Criticism of checklists Future
studies
Slide 21
Summary CISD-use errors occur at some undetermined rate The
causes and determinants for surgical errors are likely the same for
CISD-use errors A device-use checklist could be explored as an
intervention